J.S. Pearse, JefferyA. Marston
1854 The Lancet  
125 allowed it to collapse, its evacuation would probably have only rendered it the seat of an exhausting suppuration that such a patient could hardly have borne up against. In short, we should but have exchanged a cyst for an abscess. Hence I determined to forego attempting a, permanent cure.* * Limited to a palliative treatment, my chief efforts were directed to checking the bronchitis and dyspepsia, and stipporting the general health. Alkalies, aperients, and expectorants, with occasional
more » ... with occasional dry cuppings, and subsequently tonics and a generous diet, tolerably answered these indications; and the patient was discharged from the hospital, after a few weeks, very much relieved of all her more distressing symptoms. For some months I saw her occasionally as an out-patient, her appearance and bulk being little altered. On the 19th of October she was re-admitted. She had had diarrhoea, for some days, but not very severely, and latterly it had nearly ceased. As soon as I saw her it became evident to me that she would scarcely survive the attack. Without any remarkable pain, with a tolerable pulse, and an intellect quite unaffected, her face had a peculiar look of depression and anxiety, such as suggested the gravest apprehension. On examining the bslly, I found it in exactly the same state as when I had last seen her, save that there was rather more tenderness in the region of the tumour itself. She also complained of dull but constant pain here. The next day the soreness in the neighbourhood of the tumour increased, and slight vomiting came on. In about twenty-four hours more I found that the belly had undergone a remarkable change in appearance,-the tumour having disappeared, and the flaccid abdomen containing fluid in greatly increased quantity. Some tenderness could now be detected everywhere; but its amount was nothing like what is ordinarily seen in the peritonitis produced by the bursting of a cyst, nor were there any marked general symptoms of iii4.lammot'lon. In short, all other symptoms seemed to have merged in that of prostration, by the rapid increase of which the patient was carried of in about sixty hours from the rupture of the cyst. The treatment had so little effect in controlling the progress of the attack, that I need only allude to it incidentally. The patient was from the first placed on a moderate allowance of brandy in very small quantities, together -with opium, aromatic confection, sal volatile, and rhubarb. Latterly morphia, ammonia, and ether, were substituted for these drugs, and hot fomentations were frequently applied to the belly. The examination of the body verified the diagnosis which had been arrived at during life. The atrophied liver was involved in the under surface of a large cyst, the fibrous outer tunic of which had ruptured at its most anterior part, and thus effused a large quantity of fluid -into the cavity of the belly, together with a little blood. The intestines were healthy; the peritoneum, though less shining and smooth than natural, exhibited scarce a trace of inflammation on either its visceral or peritoneal surface. Here and there a minute shred of lymph was seen adhering to it, and one or two similar but rather larger flakes were found in the fluid occupying its cavity. The fibrous coat of the cyst was much thinned in the neighbourhood of the rupture, and its tissue contained small masses of coagulated blood. On laying open this fibrous coat, the collapsed and ruptured proper gelatinous cyst was found lying in contact with its interior surface. It had contracted greatly, so as to appear disproportionately small, and its elasticity had also thrown its surface into numerous wavy convolutions. Two or three smaller cysts occupied pouches split from the laminae of its outer surface. But neither these nor the larger cyst contained any Echinococci. The earlier features of the patient's last illness seem sufficiently explained by the diarrhcea, and by her previous debility. The rupture appears to have been preceded by a very active absorption, which was accompanied by hsemorrhage, and was apparently somewhat akin to ulceration. What share the diarrhoea had in inducing it must remain doubtful. The slight reaction of the system against the rupture and effusion is very remarkable, and can hardly be doubted to have been a * I need scarcely say that such an operation would be very rarely indicated. A similar case, in an earlier stage, and a healthier subject, might certainly be (7evoieof some of the objections which contra-indicated its performance in this particular instance. But I suspect that in such a favourable condition a secure diagnosis would often fail us. For even in the above patient it required very careful manipulation, and a delicate sense of touch, to verity the fluctuation which formed one main element of the diagnosis. And hence, while I did not hesitate to compromise myself bv a definite opinion, I could not help feeling gratified that I was not called upon to make it the basis of a dangerous operation. result of the extreme weakness of the sufferer. And however unsatisfactory the termination of this case, I think its history suffices to indicate, that a careful observation and interpretation of symptoms might often enable us to recognise this class of abdominal tumours, not only during the life of the patient, but at a comparatively early date of the existence of such cysts, when, if ever, the question of their obliteration could be entertained. Brooy-street, Grosvenor-square, Jan. 1854.
doi:10.1016/s0140-6736(02)40209-7 fatcat:lxxujln62rddpims6joo36p2tq